What is the treatment for postpartum hypertension?

Treatment of Postpartum Hypertension

For postpartum hypertension, initiate immediate IV antihypertensive therapy for severe hypertension (BP ≥160/110 mmHg lasting >15 minutes), and transition to oral agents compatible with breastfeeding once controlled, with nifedipine extended-release or labetalol as first-line options for persistent mild-moderate hypertension. 1

Acute Management of Severe Hypertension (BP ≥160/110 mmHg)

Severe postpartum hypertension constitutes a hypertensive emergency requiring treatment within 30-60 minutes to prevent stroke and end-organ damage. 1

First-Line IV Medications for Acute Control

• Labetalol IV: Start with 20 mg IV bolus, followed by 40-80 mg every 10 minutes until desired effect or maximum cumulative dose of 300 mg 1
• Hydralazine IV: Start with 5 mg IV initially, then 5-10 mg IV every 30 minutes as needed (note: no longer preferred due to association with more perinatal adverse effects) 1
• Nicardipine IV infusion: Start at 5 mg/h, increase by 2.5 mg/h every 5-15 minutes to maximum of 15 mg/h 1
• Oral immediate-release nifedipine: 10-20 mg orally can be used as first-line for acute severe hypertension 1

Target Blood Pressure Goals

• Reduce mean arterial pressure by 15-25% 1
• Target systolic BP 140-150 mmHg and diastolic BP 90-100 mmHg 1
• Continuous blood pressure monitoring is required during acute treatment 1

Oral Antihypertensive Therapy for Persistent Hypertension

First-Line Oral Agents (All Compatible with Breastfeeding)

Calcium channel blockers are preferred due to once-daily dosing and potentially superior efficacy compared to labetalol in the postpartum period. 1

• Nifedipine extended-release: 30-60 mg once daily (preferred first-line option) 1, 2
• Amlodipine: 5-10 mg once daily (provides once-daily dosing with potentially fewer discontinuations due to side effects) 1
• Enalapril: 5-20 mg once daily (requires documented contraception plan due to teratogenicity risk in future pregnancies) 1, 2
• Labetalol: 200-800 mg twice daily or more frequently (alternative option but may be less effective postpartum with higher readmission risk compared to calcium channel blockers) 1

Treatment Thresholds

• Initiate treatment for BP ≥140/90 mmHg confirmed on 2 separate occasions at least 15 minutes apart 1, 2
• Any hypertension before day 6 postpartum should be treated with antihypertensive therapy 2
• Recent evidence suggests that initiating therapy at 140/90 mmHg vs 150/95 mmHg does not significantly reduce maternal morbidity, though guidelines still recommend the lower threshold 3

Critical Medications to AVOID

• Methyldopa: Should be avoided postpartum due to increased risk of postpartum depression 1, 4
• Atenolol: Should not be used due to risk of fetal growth restriction 1
• Diuretics (furosemide, hydrochlorothiazide, spironolactone): May reduce milk production and should be avoided unless specifically indicated 1, 2, 5
• NSAIDs: Avoid for postpartum analgesia in women with preeclampsia, especially those with renal disease, placental abruption, acute kidney injury, or other risk factors, as NSAIDs can worsen hypertension 1, 2, 5

Monitoring and Follow-Up

Immediate Postpartum Period (Days 0-3)

• Close blood pressure monitoring is essential for at least 3 days postpartum, as this is when BP peaks and the majority of hypertension-related maternal deaths occur, including from stroke and cardiomyopathy 1, 2, 5
• Monitor BP at least every 4 hours while awake for the first 3 days 2, 5
• Assess for warning signs: severe headache, visual disturbances, chest pain, dyspnea, abdominal pain, altered mental status, or seizures 1, 5
• Do not discharge patients with preeclampsia without a clear BP monitoring plan for the critical first 3-7 days 1

Ongoing Management (Days 4-42)

• Continue antihypertensive medications from pregnancy with gradual tapering over days to weeks rather than abrupt cessation 2, 5
• Home blood pressure monitoring is recommended for ongoing assessment 2
• Withdraw antihypertensive therapy slowly, not abruptly, and continue until BP normalizes (may take days to several weeks) 5

Long-Term Follow-Up

• All women with hypertension in pregnancy should have BP and urine checked at 6 weeks postpartum 1, 2, 5
• Persistent hypertension should be confirmed by 24-hour ambulatory monitoring 1, 2
• Women with persisting hypertension under age 40 should be assessed for secondary causes 1, 2
• Review at 3 months postpartum to ensure BP, urinalysis, and laboratory abnormalities have normalized 2, 5
• If proteinuria or hypertension persists at 6 weeks, refer to a specialist 1, 2

Criteria for ICU Transfer

Consider ICU transfer if any of the following develop: 1, 5

• Heart rate >150 or <40 bpm
• Tachypnea >35/min
• Acid-base imbalance or severe electrolyte abnormalities
• Need for respiratory support or possible intubation
• Need for pressor support or cardiovascular support
• Need for IV antihypertensive medication after first-line drugs have failed
• Abnormal ECG findings requiring intervention

Long-Term Cardiovascular Risk Management

• Women with pregnancy-related hypertensive disorders are at significantly increased risk of developing chronic hypertension, stroke, ischemic heart disease, and thromboembolic disease later in life 1, 2, 5
• Annual medical review is advised lifelong 2, 5
• Aim to achieve pre-pregnancy weight by 12 months and limit interpregnancy weight gain 2, 5
• Adopt healthy lifestyle including regular exercise, healthy diet, and maintaining ideal body weight 2, 5
• Cardiovascular risk assessment and lifestyle modifications are recommended for all women with pregnancy-related hypertensive disorders 1, 2
• Document contraception plan, especially if prescribing ACE inhibitors or ARBs due to teratogenicity risk 1